The aim of this study was to assess the impact of BMI on perioperative outcomes in patients undergoing VATS lobectomy or segmentectomy. Data from 5088 patients undergoing VATS lobectomy or segmentectomy, included in the VATS Group Italian Registry, were collected. BMI (kg/m2) was categorized according to the WHO classes: underweight, normal, overweight, obese. The effects of BMI on outcomes (complications, 30-days mortality, DFS and OS) were evaluated with a linear regression model, and with a logistic regression model for binary endpoints. In overweight and obese patients, operative time increased with BMI value. Operating room time increased by 5.54 minutes (S.E. = 1.57) in overweight patients, and 33.12 minutes (S.E. = 10.26) in obese patients (P < 0.001). Compared to the other BMI classes, overweight patients were at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications. In the overweight range, a BMI increase from 25 to 29.9 did not significantly affect the length of stay, nor the risk of any complications, except for renal complications (OR: 1.55; 95% CI: 1.07–2.24; P = 0.03), and it reduced the risk of prolonged air leak (OR: 0.8; 95% CI: 0.71–0.90; P < 0.001). 30-days mortality is higher in the underweight group compared to the others. We did not find any significant difference in DFS and OS. According to our results, obesity increases operating room time for VATS major lung resection. Overweight patients are at the lowest risk of pulmonary, acute cardiac, surgical, major, and overall postoperative complications following VATS resections. The risk of most postoperative complications progressively increases as the BMI deviates from the point at the lowest risk, towards both extremes of BMI values. Thirty days mortality is higher in the underweight group, with no differences in DFS and OS.

Background Chylothorax is a relatively rare complication after surgery of the mediastinum. The occurrence and the results of surgical treatment of this condition are difficult to foresee due to the wide heterogeneity in thoracic duct anatomy. Case summary We report two cases of postoperative chylothorax treated with ligation by video-assisted thoracoscopic surgery (VATS). The first patient developed a massive left chylothorax shortly after discharge, following radical excision of a seminoma-involved left para-aortic lymphadenopathy. The second patient developed a high-output right chylothorax following VATS upper bilobectomy. In both cases, a surgical revision by VATS was performed. Inguinal injection of indocyanine green allowed an easy visualization of the lymphatic leakage point. In both cases, oral feeding was rapidly restarted after surgery. No recurrence of chylothorax was observed. Conclusion The use of indocyanine green may greatly improve the identification of the thoracic duct during surgical ligation by VATS, with a favorable impact on the postoperative course and overall admission costs.

Background: In previous multicentre studies, the longest survival was observed in synchronous lung oligometastatic patients without pN2 disease. This paper aimed to identify preoperative favourable prognostic factors and propose a preoperative classification for categorising the synchronous oligometastatic non-small cell lung cancer (NSCLC).Methods: A retrospective review of prospectively collected patients was performed. The inclusion criteria were: synchronous oligometastatic NSCLC (≤5 extrapulmonary metastases), radical surgical treatment of the primary tumour and all metastatic sites (2005–2018). Exclusion criteria were: palliative surgery, recurrent lung cancer, low-performance status, follow-up information unavailable. The reverse Kaplan – Meier method estimated median overall survival (OS) and progression-free survival. A stratified backward stepwise Cox regression model was employed for multivariable survival analyses. A prognostic grouping considering all the relevant prognostic factors simultaneously was constructed, and a Receiver Operating Characteristic (ROC) curve was generated. Hosmer-Lemeshow χ statistics was used for measuring OS calibration within groups.Findings: 281 patients were included. Data from the Cox regression model were used to construct a prognostic risk classification. Four parameters (age ≤65 years, site of metastasis, clinical nodal status, and induction treatment) were used to build a risk classification. Group A: no risk factors (age ≤65 years, lung/brain metastasis, cN0, induction treatment); Group B: one risk factor (age >65 years or no lung/brain metastasis or cN1–2 or no induction treatment); Group C: two risk factors; Group D: ≥3 risk factors. The Area Under the Curve (AUC) was 0.56 (95% CI: 0.49–0.62), Hosmer-Lemeshow χ statistics was 21.3 (3 degrees of freedom, p=0.0042).Interpretations: Patient selection is critical in identifying the proper subsets of oligometastatic NSCLC. After clinical validation, this preoperative risk classification might support decision-making during the multidisciplinary team assessment and patient selection for enrolment in future randomised trials.Funding: This work was partially supported by the Italian Ministry of Health with Ricerca Corrente and 5 x 1000 funds.Declaration of Interest: All authors have no conflict of interest to declare.Ethical Approval: This research was carried out following the Helsinki Declaration 10. The Ethical Committee authorised the study (785/19).

Background: Pleural malignancies are challenging conditions in terms of possibility of cure. Recent growing interest towards Hyperthermic Intrathoracic Chemotherapy (HITHOC) after Cytoreductive Surgery (CRS) has been referred. Minimally invasive approach (VATS) may be suggest in this context but evidence is still lacking. Methods: A preliminary experience in seven patients submitted to cytoreductive surgery and HITHOC is described, with a focus on technical aspects related to VATS approach, operating median time and postoperative complication. Results: A triportal VATS approach has been employed in all cases. Median time of surgery including pleural perfusion was 200 min (range 165 to 370). Mean blood loss was 217 cc (range 100 and 600). Thirty days mortality was nothing. Conclusion: VATS cytoreductive surgery and HITHOC is a safe procedure and could be proposed in the setting of a multimodality strategy employing adjuvant radio-chemotherapy in referral centers.

Background: Digital chest drainage could estimate risk of prolonged air leaks (PAL) Aim: Evaluation of relationships between airflow and intrapleural pressure (IPP) after Video-Assisted lobectomies for lung cancer Methods: Multicentre retrospective analysis. Multiple measurements (every min) of airflow and minimum/maximum IPP digitally recorded using microelectronic mechanical sensor technology. Mathematical analysis of IPP was done with subsequent multivariable analysis Results: 94 patients (July 2019–December 2020). No pneumothorax/subcutaneous emphysema following removal of chest tube. 24 patients (25.5%) had PAL (≥5 days). COPD patients, FEV1%/DLCO/VA% were not significantly different between groups. There were no differences between groups as concerns VATS approaches and resected lobe (upper lobectomies more frequently PAL related). Minimum/maximum IPP was significantly less negative in PAL groups after 7th postoperative hours. A shift in first derivative of IPP curve after 7th hours was predictor of PAL resolution (OR=2.3, 95%CI: 1.7–3.1, p=0.002) Conclusions: PAL showed less negative IPP on first day. After 7th hours, modification in first derivative of IPP curve was critical. Absence of a first derivative shift allows defining patients likely to develop PAL. Mathematical analysis can improve standardization in chest tube management after lung resection

Background The role of video-assisted thoracoscopic surgery for the treatment of non-small-cell lung cancer after neoadjuvant chemotherapy remains controversial. The aim of this study is to demonstrate the reliability of video-assisted lobectomy compared to the open approach by evaluating perioperative and long-term outcomes. Methods In this retrospective, multicentric study from January 2010 to December 2018, we included all patients with non-small-cell lung cancer who underwent lobectomy through the video-assisted or open approach after neoadjuvant chemotherapy. The perioperative outcomes, including data concerning the feasibility of the surgical procedure, the occurrence of any medical and surgical complications and long-term oncological evidence, were collected and compared between the two groups. To minimize selection bias, propensity score matching was performed. Results A total of 286 patients were enrolled: 193 underwent thoracotomy lobectomy, and 93 underwent VATS lobectomy. The statistical analysis showed that surgical time ( P < 0.001), drainage time ( P < 0.001), days of hospitalization ( P < 0.001) and VAS at discharge ( P = 0.042) were lower in the VATS group. The overall survival and disease-free survival were equivalent for the two techniques on long-term follow-up. Conclusions VATS lobectomy represents a valid therapeutic option in patients affected by non-small-cell lung cancer after neoadjuvant chemotherapy. The VATS approach in our experience seems to be superior in terms of the perioperative outcomes, while maintaining oncological efficacy.

In our previous multicentre study (Lung Cancer, 2021;154:29-35), longest survival was observed in synchronous lung oligometastatic/non pN2 disease. Aims. To identify preoperative favourable prognostic factors and to propose a preoperative classification for categorising the synchronous oligometastatic NSCLC.

Londero F1*, Masullo G1*, Grossi W1, Franceschi ED1, Cinel J1, Vernaccini N2, de Manna ND1, Bacchetti S2, Vendramin I1, Adani G2, Morelli A1 and Pasqual EM2 1Cardiothoracic Surgery Department, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital Santa Maria della Misericordia, Udine, Italy 2Center for Advanced Surgical Oncology, Department of General Surgery, Azienda Sanitaria Universitaria Friuli Centrale, University Hospital Santa Maria della Misericordia, Udine, Italy

BACKGROUNDS:Oligometastatic Non-Small Cell Lung Cancer (NSCLC) patients represent a category without a standard therapeutic approach. However, in selected oligometastatic NSCLC, radical surgery seems to offer a good prognosis. This retrospective study aimed to analyse the long-term outcomes of synchronous oligometastatic patients treated with curative intent and identify the factors associated with better results and the proposal of a risk stratification system for classifying the synchronous oligometastatic NSCLC. METHODS:The medical records of patients from 18 centres with pathologically diagnosed synchronous oligometastatic NSCLC were retrospectively reviewed. The inclusion criteria were synchronous oligometastatic NSCLC, radical surgical treatment of the primary tumour with or without neoadjuvant/adjuvant therapy and radical treatment of all metastatic sites. The Kaplan - Meier method estimated survivals. A stratified backward stepwise Cox regression model was assessed for multivariable survival analyses. RESULTS:281 patients were included. The most common site of metastasis was the brain, in 50.89 % patients. Median overall survival was 40 months (95 % CI: 29-53). Age ≤65 years (HR = 1.02, 95 % CI: 1.00-1.05; p = 0.019), single metastasis (HR = 0.71, 95 % CI: 0.45-1.13; p = 0.15) and presence of contralateral lung metastases (HR = 0.30, 95 % CI: 0.15 - 0.62; p = 0.001) were associated with a good prognosis. The presence of pathological N2 metastases negatively affected survival (HR = 2.00, 95 % CI: 1.21-3.32; p = 0.0065). These prognostic factors were used to build a simple risk classification scheme. CONCLUSIONS:Treatment of selected synchronous oligometastatic NSCLC with curative purpose could be conducted safely and at acceptable 5-year survival levels, especially in younger patients with pN0 disease.

Pulmonary sequestrations are rare congenital malformations. They are often located in the lower lobes, and they are supplied by an aberrant systemic vessel arising from the thoracic aorta or abdominal arteries. These pulmonary malformations are divided into intra- and extralobar sequestrations, depending on the respective lack or presence of an independent pleural covering. Pulmonary sequestration can be asymptomatic or lead to recurrent pulmonary infections. The goal of this study was to analyse the feasibility and safety of a hybrid sequential approach. We report a small series of intralobar pulmonary sequestrations, from November 2017 to December 2018, successfully treated with a hybrid minimally invasive approach consisting of endovascular embolization of the aberrant arterial branch followed by video-assisted thoracoscopic lobectomy the day after. Thoracic pain following endovascular embolization was noted in all cases. Patients were discharged early in the absence of major postoperative complications. Prolonged air leak was observed in only 1 case. Despite the presence of sequestration-related pulmonary inflammation, in our experience, hybrid treatment for intralobar pulmonary sequestration is a safe and reproducible approach in terms of postoperative complications and hospital stay.

OBJECTIVES Digital chest drainage systems allow real-time and continuous monitoring and recording of air leak flow rate and intrapleural pressure (IPP) from the immediate postoperative period to the chest drainage removal. A multicentre retrospective observational analysis of consecutive patients undergoing pulmonary lobectomy for lung cancer was performed to evaluate the association between the airflow and IPP digitally recorded during the immediate postoperative period after video-assisted thoracic surgery (VATS) lobectomy for lung cancer. Here, we present a work in progress report. METHODS All patients treated with VATS lobectomies for lung cancer were included. Multiple airflow measurements and minimum and maximum IPP through the chest tubes were digitally monitored and recorded using microelectronic mechanical sensor technology. The PALs were defined as an air leak lasting >5 days from the conclusion of the surgical procedure. The cessation of air leaks was defined as an airflow <10 ml/min during 6 consecutive hours. RESULTS This analysis comprised 76 patients who underwent VATS lobectomy for lung cancer. Nineteen patients (25%) showed prolonged air leaks (PAL) (≥5 days). The operative time was higher in the PAL group (mean difference = 44 min) without a statistically significant difference. Before the 7th postoperative hours, there were no statistically significant differences in IPPs. CONCLUSIONS Patients with PAL showed less negative IPP in the first 24 postoperative hours. Therefore, the 7th-24th postoperative hours were critical in PAL prediction since the mechanism for PAL seems to develop after the 7th postoperative hour.

Obesity correlates with better outcomes in many neoplastic conditions. The aim of this study was to assess its role in the prognosis and morbidity of patients submitted to resection of lung oligometastases from colorectal cancer. Seventy-six patients undergoing a first pulmonary metastasectomy were retrospectively included in the study. Seventeen (22.3%) were obese (body mass index (BMI) >30 kg/m2). Assessed outcomes were overall survival, time to recurrence, and incidence of post-operative complications. Median follow-up was 33 months (IQR 16–53). At follow-up, 37 patients (48.6%) died, whereas 39 (51.4%) were alive. A significant difference was found in the 3-year overall survival (obese 80% vs. non-obese 56.8%, p = 0.035). Competing risk analysis shows that the cumulative incidence of recurrence was not different between the two groups. Multivariate analysis reveals that the number of metastases (p = 0.028), post-operative pneumonia (p = 0.042), and DFS (p = 0.007) were significant predictors of death. Competing risk regression shows that no independent risk factor for recurrence has been identified. The complication rate was not different between the two groups (17.6% vs. 13.6%, p = 0.70). Obesity is a positive prognostic factor for survival after pulmonary metastasectomy for colorectal cancer. Overweight patients do not experience more post-operative complications. Our results need to be confirmed by large multicenter studies.

The proportion of octogenarian patients is growing over years. Nowadays video-assisted thoracoscopic surgery (VATS) permits to treat old age patients, even with limited pulmonary function, not otherwise suitable for surgery. The aim of our study is to analyse the factors influencing short and long terms outcome of the octogenarian patients underwent VATS lobectomy. Between January 2013 and March 2019 we performed 292 VATS lobectomies of which 26 patients were octogenarian. The patients’ population were divided in two groups according to patient’s age (group 1: patient younger than 80 years old; group 2: older than 80 years old). The octogenarian patients had higher post-operative complication (POC) rate and hospital stay than the younger patients. Surgeon’s learning curve was significantly associated to higher POC in both group of patients (group 1: P<0.002, group 2: P<0.001). Patients of both groups who underwent VATS lobectomy performed by resident surgeon supported by a skilled tutor had a significantly lower risk of POC (group 1 and group 2: P<0.001). Right upper lobectomy was significantly associated to higher risk of POC in both groups [group 1: P<0.008, relative risk (RR) =1.7 and group 2: P<0.032, RR =1.5] whereas left lower lobectomy showed higher risk of POC only in group 1 (P<0.03, RR =1.9). Hospital stay was significantly influenced by POC (group 1: P<0.001, group 2: P<0.03) and by post-operative atrial fibrillation in octogenarian group (P<0.04). Overall survival was influenced by lung cancer’s stage but not by age and POC in both groups. In conclusion octogenarian patients should undergo surgery after a completed pre-operative assessment due to their comorbidities. Post-operative outcome and overall survival of elderly patients are comparable with younger patients.

Open thoracotomy during pulmonary metastasectomy allows lung palpation and may discover unexpected further nodules. We assess the validity of intraoperative lung ultrasonography via thoracoscopy in identifying lung nodules. A first surgeon will perform an ultrasonographic investigation on the deflated lung by thoracoscopy. A second surgeon will then perform a manual exploration of the organ by thoracotomy. Data on number and localization of nodules will be matched and compared with final histology report. Sensitivity and specificity will be assessed. Concordance will be assessed with Cohen K test. Calculated sample size is 89 patients. This study might have an important role in shifting the surgical practice towards a less invasive approach, with consequent benefits for the patient. Protocol is registered on clinicaltrials.gov. Protocol registration number: NCT03864874.

The aim of this study was to assess the prognostic value of preoperative neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) levels in patients undergoing resection of pulmonary oligometastases. A retrospective analysis on 141 patients undergoing a first pulmonary metastasectomy in a single center was carried out. Two distinct analysis were performed subdividing patients according to their NLR ratio and CRP level. The main outcomes were survival and time to recurrence. At completion of follow-up 74 patients were still alive (52.5%). Subdividing patients according to their NLR yielded a significant difference in five-year progression-free survival (PFS, NLR < 4:32% vs. NLR ≥ 4:18%, p = 0.01). When subdivided by their CRP levels, patients with preoperative CRP < 5 mg/L demonstrated higher values of five-year overall survival (OS, 57% vs. 34%, p = 0.006) and five-year PFS (35% vs. 22%, p = 0.04). At multivariate analysis, level of neutrophils (p = 0.009) and lung comorbidities (p = 0.021) were independent predictors of death, whereas preoperative CRP (p = 0.002), multiple metastases (p = 0.003) and presence of lung comorbidities (p = 0.001) were independent predictors of recurrence. NLR and CRP are important predictors of prognostic outcome in patients undergoing pulmonary metastasectomy.

It is not clear as to which is the best treatment among surgery and stereotactic radiotherapy (SBRT) for lung oligometastases. A systematic review of literature with a priori selection criteria was conducted on articles on the treatment of pulmonary metastases with surgery or SBRT. Only original articles with a population of patients of more than 50 were selected. After final selection, 61 articles on surgical treatment and 18 on SBRT were included. No difference was encountered in short-term survival between pulmonary metastasectomy and SBRT. In the long-term surgery seems to guarantee better survival rates. Mortality and morbidity after treatment are 0-4.7% and 0-23% for surgery, and 0-2% and 4-31% for SBRT. Surgical metastasectomy remains the treatment of choice for pulmonary oligometastases.

The phase IIb SENECA trial was an Italian real-world experience recently ended, which demonstrated similar progression free survival (PFS) and overall survival (OS) in non-squamous non-small cell lung cancer (nsNSCLC) patients treated with second-line docetaxel/nintedanib, regardless the relapsing-time from end of first-line chemotherapy and the docetaxel schedule employed (weekly or q3wks), with a slightly higher toxicity-trend in the q3wks arm. During accrual period (January 2016-April 2018), no therapeutic alternative to the use of docetaxel was available for patients with recurrent nsNSCLC until April 2017, when the first immune-checkpoint inhibitor was approved and reimbursed in Italy in this setting. At that point, the study was amended allowing enrolment of patients previously treated with immunotherapy (IT). Because of the lack of data about the optimal therapeutic algorithm in this context, aim of the present evaluation is to investigate if survival expectancy of patients treated with docetaxel/nintedanib could positively influenced when previously treated with IT. In the SENECA trial, 212 nsNSCLC patients, progressing after first-line chemotherapy, were treated with docetaxel plus continuous oral nintedanib, with the possibility of maintenance in case of stabilization or response. This evaluation focus on 16 patients previously treated with IT and compares them to the rest of patient population. Survival analysis is performed using Kaplan Meier curves; Hazard Ratios (HR) with 95% Confidence Interval (95%CI) are reported to compare the two groups. Patients treated with IT (2 combined with first-line chemotherapy, 14 alone) correspond to 7.5% of the entire study population; they were 9 males and 7 females, with a median age of 62.5 years, mainly current or former-smokers, with an ECOG-performance status 0 in 93.7% of cases. At the cut-off date (December 25th, 2018), after a median follow-up of 35.5 months, no significant differences appear between patients previously treated with IT and the other ones in terms of PFS (5.84 vs 4.31 months, respectively; HR 0.564 [95% CI 0.283-1.122], p-value=0.1029), and OS (9.37 vs 9.02 months, respectively; HR 1.108 [95% CI 0.393-3.123], p-value=0.8456). No significant differences have been observed also in disease-control rates (80.0% vs 66.7%, p-value=0.5436). Despite this report does not show a greater survival expectancy for patients treated with docetaxel/nintedanib and previous IT, it's likely that the small sample size may affect this result. The longer PFS and greater disease-control rate are attractive hints for future evaluations with larger sample sizes, supposing a new therapeutic algorithm for recurrent nsNSCLC patients.

Background Many new surgical techniques and materials have been introduced in the last decade for chest wall reconstruction or stabilization with the purpose of improving the incorporation, maintaining chest wall stability with reduction of infections. However, none of them are yet considered a gold standard procedure. The aim of this work is to evaluate the initial experience using a new titanium mesh for chest wall reconstruction in four Italian Thoracic Surgery Departments. Methods A review was performed of all patients undergoing chest wall reconstruction using a new titanium mesh between January 2014 and September 2018. Surgical indications, the location and size of the chest wall defect, intraoperative variables and postoperative complications were analyzed. Results A total of 26 consecutive patients were included. The most common indications for surgery were primary or secondary chest wall tumors (38%) followed by lung cancer invading chest wall (31%). The most common localization of chest wall defect was anterolateral (46%). Sternal reconstruction was required in 3 patients (12%). The average size of the defect was 9.3×7.8 cm. The median number of resected ribs was 3.6. No perioperative deaths occurred. Mean hospital stay was 11.9 days. Overall morbidity was 19%. One failure of reconstruction (4%) was reported during follow up. Conclusions In our early clinical experience chest wall reconstruction using titanium mesh can be performed as a safe and effective surgical procedure. This mesh has excellent biomechanical characteristics between rigid and malleable materials, it's easy to trim and fix for optimal adaptation without necessity of dedicated instruments. The early and mid-term results are satisfactory with low incidence of complications related to the titanium mesh implant.

Background and Objectives: Lymphadenectomy during pulmonary metastasectomy (PM) is widely carried out. We assessed the potential benefit on patient survival and tumor recurrence of this practice.

The object of our study is to show the causes leading to conversion, in order to observe the responsible variables and analyses if conversion influences the patient's outcome. Between January 2013 and December 2016, Udine Thoracic Department performed 180 video-assisted thoracoscopic surgery (VATS) lobectomies, and 24 cases were converted to thoracotomy due to an intra-operative complication such as arterial or venous bleeding, airway and other injuries. The VATS lobectomies' number increased over the three years: from 27 in 2013 to 55 in 2015 and 48 in 2016. While conversion's rate decreased from 33% in 2013 to 5.5% in 2015 and 10% in 2016. We performed a univariate and a multivariate analysis looking for the variables affecting the conversion rate. This was significantly related to intraoperative bleeding and airway injuries (P<0,001). Seventy-year older patients were not associated to a higher conversion rate, instead they showed an increased risk of post-operative complications (P<0,018, RR =1.8). We have focused our attention on all the variables leading to conversion and conditioning the patient's outcome in terms of post-operative complications and length of stay. The best strategy to face VATS complication is to prevent them. Young surgeons at the beginning of their learning curve should perform VATS lobectomies under close supervision of a skilled VATS surgeon. Moreover, conversion to open thoracotomy should be not considered a failure of VATS, but rather a procedure for patient's safety.